Emergency USMLE 3 (216-300)

A 43-year-old woman presents to the ED with a 3-week history of intermittent headache, nausea, and fatigue. She was seen at her private doctor’s office 1 week ago along with her husband and children, who also have similar symptoms. They were diagnosed with a viral syndrome and told to increase their fluid intake. She states that the symptoms began approximately when it started to get cold outside. The symptoms are worse in the morning and improve while she is at work. Her BP is 123/75 mmHg, HR is 83 beats per minute, temperature is 98.9°F, and oxygen saturation is 98% on room air. Physical examination is unremarkable. You suspect her first diagnosis was incorrect. Which of the following is the most appropriate next step to confirm your suspicion?

A 45-year-old previously healthy male is brought to the emergency room because of headaches and confusion for 2 days. He denies any focal weakness or sensory symptoms. He has no significant past medical history and does not use any medications. He does not use tobacco, alcohol or drugs. On physical exam, the patient has a temperature of 37.9°C (100.2°F), a blood pressure of 140/86 mm Hg, a pulse of 96/min, and respirations of 16/min. Mild icterus is present. The patient's oropharynx is clear and his neck is supple and without rigidity. Examination of the patient's chest and abdomen is unremarkable. Neurologic examination reveals no focal deficits. Laboratory studies show: Complete blood count: Hemoglobin 84 g/L, Platelet count 80,000/mm3, Leukocyte count 5,500/mm3. Chemistry panel:Blood urea nitrogen (BUN) 30 mg/dL, Serum creatinine 2.2 mg/dL, Serum calcium 10.0 mg/dL, Blood glucose 98 mg/dL. A peripheral blood smear shows many fragmented red blood cells. The prothrombin time is normal. Which of the following is the most appropriate next step in the management of this patient?

A 45-year-old woman is brought to the ER by ambulance after a neighbor found her to be in a somewhat obtunded state with an empty bottle of medication next to her. While en route to the ER she suffered a tonic clonic seizure. Her past medical history is significant for major depression. Her temperature is 38.3°C (100.9°F), blood pressure is 90/70 mmHg, pulse is 120/min, and respirations are 16/min. She is able to respond to painful stimuli. Pupils are 8 mm in size bilaterally. Skin is warm and flushed. Lungs are clear to auscultation. Abdomen is soft and non-tender. Bowel sounds are decreased. There is no neck stiffness. EKG shows QRS duration of 130 msec, a change from her previous EKG a month ago. Which of the following is the most appropriate next step in management?

A 46-year-old male is admitted to the hospital because of right hand cellulitis. He has a history of intravenous drug use, hepatitis C infection and septic arthritis of the knee. He smokes one pack of cigarettes and drinks one pint of vodka daily. He is started on vancomycin. On the following day, the swelling and redness of his arm decreases. However, he complains of bugs crawling on his skin. His temperature is 38.3°C (100.9°F), blood pressure is 160/90 mmHg, pulse is 110/min, and respirations are 18/min. Examination shows mild hand tremors and diaphoresis. Which of the following is the most appropriate next step in management?

A 49-year-old man presents to the clinic for a health maintenance visit. He has no complaints, but he requests a prescription for his “pressure pills,” as he lost his original prescription. On physical examination his blood pressure is 220/130 mmHg. Physical examination is otherwise within normal limits. Laboratory tests show: Na+: 142 mEq/L, K+: 3.8 mEq/L, Cl−: 105 mEq/L, Carbon dioxide: 25 mEq/L, Blood urea nitrogen: 20 mg/dL, Creatinine: 1.0 mg/dL, Glucose: 133 mg/dL. Urinalysis is within normal limits, and his ECG is normal. Which of the following is the most effective management?

A 5-year-old boy is brought into the ER immediately after an unfortunate altercation with a neighbor’s immunized Chihuahua that occurred while the child was attempting to dress the dog as a superhero. The fully immunized child has a small, irregular, superficial laceration on his right forearm that has stopped bleeding. His neuromuscular examination is completely normal, and his perfusion is intact. Management should include which of the following?

A 54-year-old man is brought to the ER because of an episode of coffee ground emesis and lightheadedness. He has a history of intravenous drug use, hepatitis C infection, and alcohol use. He says he has not had an alcoholic drink for about three days. He has been noncompliant with medications and follow-ups. He takes no medications. His temperature is 36.7°C (98°F), pulse is 110/min, respirations are 16/min, and blood pressure is 90/60 mmHg. Scleral icterus is present. Examination shows coffee ground material in the oropharynx. His lungs are clear. His abdomen is distended and a fluid wave is present. He is slightly tender to palpation in the epigastrium. Laboratory studies show: Complete blood count:Leukocyte count 9,500/mm3, Hemoglobin 10.0 g/L, Platelets 120,000/mm3. Chemistry panel:Serum sodium 140 mEq/L, Serum potassium 3.5 mEq/L, Bicarbonate 27 mEq/L, Blood urea nitrogen (BUN) 34 mg/dL, Serum creatinine 0.8 mg/dL. Coagulation studies :Prothrombin time 27 sec, Partial thromboplastin time 42 sec. Which of the following is the most appropriate next step in the management of this patient?

A 55-year-old man presents to the ED with fever, drooling, trismus, and a swollen neck. He reports a foul taste in his mouth caused by a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and protrusion of the tongue. He appears “bull-necked” with tense and markedly tender edema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphadenopathy. These lungs are clear to auscultation with good air movement. His vital signs are HR 105 beats per minute, BP 140/85 mmHg, RR 26 breaths per minute, and temperature 102°F. Which of the following is the most appropriate next step in management?

A 59-year-old woman with renal cell carcinoma presents to the emergency department with severe right upper quadrant (RUQ) pain. She is afebrile, acutely tender in the RUQ, and has shifting dullness and a palpable liver edge. Murphy’s sign is negative. Laboratory studies show: Na+: 138 mEq/L, K+: 3.6 mEq/L, Glucose: 80 mg/dL. Aspartate aminotransferase: 50 U/L Alanine aminotransferase: 43 U/L Alkaline phosphatase: 138 U/L Total protein: 6.4 g/dL, Albumin: 3.8 g/dL, Total bilirubin: 1.1 mg/dL. Imaging demonstrates a spider web of collateral veins in the liver. Although extensive measures are taken, the patient dies 6 hours after arriving. Which of the following was the most likely initial treatment?

A 60-year-old male is found lying down on the street by police one winter morning. He has been taking ibuprofen for headaches, fluphenazine for his schizophrenia and amitriptyline for chronic painful neuropathy secondary to post-herpetic neuralgia. He is also receiving cephalexin for cellulitis of the right lower leg. His temperature is 34°C (90°F), blood pressure is 80/50 mmHg, pulse is 88/min, and respirations are 12/min. Which of the following medications most likely have contributed to the development of hypothermia in this patient?

A 61-year-old man with a history of depression and hypertension is brought to the ED by EMS for altered mental status. The patient’s wife states that he stopped taking his fluoxetine 1 month ago and now only takes metoprolol for his hypertension. The patient’s BP is 75/40 mmHg, HR is 39 beats per minute, RR is 14 breaths per minute, oxygen saturation is 99% on 100% oxygen, and fingerstick glucose is 61 mg/dL. The patient is awake and moaning, responding only to deep stimuli. His extremities are cool to the touch. You suspect an overdose of metoprolol. You endotracheally intubate the patient for airway control. Which of the following is the most appropriate next step in management?

A 62-year-old man presents to the ED with gradual dyspnea over the last few weeks. He reports that he is a daily smoker and has not seen a physician in years. Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. A thoracentesis is performed. Given this patient’s history, which of the following most likely describes his effusion?